CMS audits for risk adjustment will RADV be upgraded and intensified

POST UNITED, HUMANA, FREEDOM INVESTIGATIONS?

When CMS proposed expanding the risk adjustment audit program in 2015, it was looking to

cover all Medicare Advantage (MA) Plans, annually. CMS wanted one of two conditions:

1. Condition-Specific

2. Comprehensive Audits

CMS wanted one of the two implemented due to the fact that the powers at be then, strongly

believed that the diagnosis data was fraught with epic upcoding mistakes which were being

submitted by all the MA organizations. This was a concern for CMS as they were concerned

that there would be significant misallocation of resources. Some MA Plans might be

overpaid on their members and some might be underpaid on their members.

At the time, CMS audited only five percent of

all MA Plans annually and that is still in place as
of 2017. In order for CMS to move to one of the
two models it is looking to adopt, there will have
to be significant policy changes. In light of recent
headlines, alleging upcoding by The Big Three United, Humana, Freedom and
other MA Plans and the DOJ stepping in it would seem that 2017 may be the year of
the MARADV overhaul.

Related webinar: Risk Adjustment and RADV Audit webinar video

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What we know:
MAS & Providers feeling increased pressure for accuracy

Risk Score Accuracy is Mission Critical to avoid upcoding or HCC Creep

OIG will add to annual Work Plan most likely in light of the big three fraud
investigations this year

RAC intensity possible also on the heels of the big three fraud investigations this year
RAPS (Risk Adjustment Processing System) to EDPS (Encounter Data Processing
System)- as of 2020, MAPlans will be subject to 100% EDPS for records
(currently 25% of Risk Scores are based on EDPS/75% is RAPS)

Tighter Filters in 2020 to more accurately determine Risk Scores

Could result in possible 3-4% downtick impact for some MA Plans, if they dont
implement changes now to how they capture HCCs/RXHCCs

Sunset of RAPS by 2020 it is proving to be an outdated and inaccurate model to

capture RA data during sweeps

Two audit types for RADV

CMS and HHS each have their own version of RADV Audits they conduct based on two

different HCC coding models: CMS-HCCs and HHS-HCCs. Each model is designed to

capture population complexity and severity. To be more specific, the CMS/HCC model was

adapted into the HHS/HCC Model and is utilized within some of the Alternate Payment

Models (APMs), which also includes Advanced APMs.

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 CMS RADV
CMS-RADV audits are occur annually and are comprised of two focus areas:

National Sample which consists of a small group of MA Plan members and focus on
calculating error rates without identifying financial impact

Targeted Audits are broader and intensive in nature. They are made up of a random
sample from 201 MA Plan members. Targeted audits place the
burden of proof on the MA Plan, to produce a valid face to face
encounter for each date of service/claim submitted previously by
the MA Plan. Each medical record must be able validate each reported diagnosis that
correlates to an HCC/RXHCC submitted to CMS by the MA Plan.

HHS RADV
All MA Plans are required to annually participate in a Health Exchange or (HIX), RADV

audit. These audits are comprised of a 200 Plan member sample for

each MA Plan. HHS RADV Audits, also place the burden of proof on

the MAPlan, to produce a valid face to face encounter for each date of

service/claim submitted previously by the MA Plan. Each Medical

record must be able validate each reported diagnosis that correlates to an HCC/RXHCC

submitted to HHS/CMS, by the MA Plan. The HIX HCC Program is designed based on

budget neutrality and the outcome will reflect MA Plan performance and overall drive the

payments owed to all competing MA Plans.

Request for RADV audit worth $ 2000 + 30 minutes consultation worth $ 250
completely free

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THE RADV CHECKLIST
Member Name: HCN:

Image ID: ________ DOS:________ Page #: ________

HCC: Diagnosis Code(s): ___________________________

Is the correct member name on the Admission or Date of Service (ADM/DOS)?

Is the ADM/DOS for the correct year?

Does the documentation support a face-to-face visit?

Is the ADM/DOS from a valid provider type and setting?

Is the provider credentials/specialty documented on the ADM/DOS?

Does the ADM/DOS contain an acceptable (legible) signature with date?

If not, is a CMS-Generated Attestation needed for this DOS?

Is the record for the correct calendar year for the payment year being audited?

Is the date of service present for the face to face visit?

Is the record legible?

Is the record from a valid provider type?

Are there valid credentials and/or is there a valid physician specialty documented on the
record?

If the outpatient/physician record doesnt contain a valid credential and/or signature, is

there a completed CMS-Generated Attestation for this date of service?

Is there a current (legible) diagnosis that supports the HCC requested?

If yes, does condition meet reporting criteria (MEAT)?

If not, does the documentation support a higher weighted HCC?

If not, does the documentation support a lower weighted HCC?

Are any additional HCCs supported on this ADM/DOS?

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The wrap up

We know there is active talk of CMS creating a new kid

on the block for Risk Adjustment Audits, the Medicare

Advantage Recovery Audit Contractor Program,

(MARA? Possibly our new acronym). If CMS does

move forward this year or next and create a bigger,

badder, version of RADV, I venture to say that MA Plans

and Providers will need to work together, along with

Certified Risk Adjustment Coders (CRC). They all will have to be focused on compliance

with any new requirements/ changes that may be implemented under a potential a MARA

Contracting Program. Additionally, I will venture to say that extrapolation, may well be

involved in any investigated and proved cases.

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